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Hand and Arm Pain: Joseph A Gregory R. Waryasz, MD; Todd Borenstein, MD; Robert Tambone, MS; Hand and arm pain: Joseph A. Gil, MD; Manuel DaSilva, MD Department of Orthopaedic A pictorial guide to injections Surgery, Brown University/- Rhode Island Hospital, Provi- dence (Drs. Waryasz, This article, with illustrative figures, will help you get Borenstein, Gil, and DaSilva); New York Medi- to the cause of your patient’s pain and guide your cal College, Valhalla (Dr. Tambone) administration of corticosteroid injections. gregory.waryasz.md@ gmail.com The authors reported no potential conflict of interest rimary care physicians are frequently the first to evaluate relevant to this article. PRACTICE hand, wrist, and forearm pain in patients, making knowl- RECOMMENDATIONS edge of the symptoms, causes, and treatment of common ❯ Diagnose common upper P diagnoses in the upper extremities imperative. Primary symp- extremity conditions based on toms usually include pain and/or swelling. While most tendon anatomic relationships. B disorders originating in the hand and wrist are idiopathic in ❯ Refer patients who do not nature, some patients occasionally report having recently per- respond to splinting, corti- formed unusual manual activity or having experienced trauma costeroid injections, or other to the area days or weeks prior. A significant portion of patients conservative therapies to a are injured as a result of chronic repetitive activities at work.1 surgeon for evaluation. B Most diagnoses can be made by pairing your knowledge Strength of recommendation (SOR) of hand and forearm anatomy with an understanding of which A Good-quality patient-oriented tender points are indicative of which common conditions. evidence (Care, of course, must be taken to ensure that there is no un- B Inconsistent or limited-quality patient-oriented evidence derlying infection.) Common conditions can often be treated C Consensus, usual practice, nonsurgically with conservative treatments such as physical opinion, disease-oriented therapy, bracing/splinting, nonsteroidal anti-inflammatory evidence, case series drugs (NSAIDs), and injections of corticosteroids (eg, beta- methasone, hydrocortisone, methylprednisolone, and triam- cinolone) (TABLE 12-4) with or without the use of ultrasound. The benefits of corticosteroid injections for these conditions are well studied and documented in the literature, although physicians should always warn patients of the possible adverse effects prior to injection3,5 (TABLE 24). To help you refine your skills, we review some of the more common hand and forearm conditions you are likely to en- counter in the office and provide photos that reveal underly- ing anatomy so that you can administer injections without, in many cases, the need for ultrasound. Trigger finger/thumb: New pathophysiologic findings? Trigger finger most commonly occurs in the dominant hand. It is also more common in women, patients in their 50s, and 492 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 Most diagnoses can be made by pairing your knowledge of hand and forearm anatomy with an understanding of which tender points are indicative of which common conditions. in individuals with diabetes.6 Trigger finger/- grecan, and biglycan are up-regulated, while thumb is caused by inflammation and con- metalloproteinase inhibitor 3 (TIMP-3) and striction of the flexor tendon sheath, which matrix metallopeptidase3 (MMP-3) are down- carries the flexor tendons through the palm regulated, a situation also described in Achil- and into the fingers and thumb. This, in turn, les tendinosis.7 This similarity in conditions causes irritation of the tendons, sometimes provides new insight into the pathophysiology via the formation of tendinous nodules, of the condition and may help provide future which may impinge upon the sheath’s “pulley treatments. system.” ❚ When the “pulley” is compromised. Making the Dx: The retinacular sheath is composed of 5 an- Look for swelling, check for carpal tunnel nular ligaments, or pulleys, that hold the During the examination, first look at both tendons of the fingers close to the bone and hands for swelling, arthropathy, or injury, allow the fingers to flex properly. The A1 pul- and note the presence of any joint contrac- ley, at the level of the metacarpal head, is the tures. Next, examine all of the digits in flex- first part of the sheath and is subject to the ion and extension while noting which ones highest force; high forces may subsequently are triggering, as the problem can occur in lead to the finger becoming locked in a flexed, multiple digits on one hand. Then palpate the or trigger, position.6 Patients may experience palms over the patient’s metacarpal heads, pain in the distal palm at the level of the feeling for tender nodules. A1 pulley and clicking of the finger.6 Finally, examine the patient for carpal IMAGE: © JOE GORMAN ❚ Additionally . recent studies show tunnel syndrome (CTS). A positive Tinel’s discrete histologic changes in trigger finger sign (shooting pain into the hand when the tendons, similar to findings with Achilles median nerve in the wrist is percussed), a tendinosis and tendinopathy.7 In trigger fin- positive Phalen maneuver (numbness or ger tendons, collagen type 1A1 and 3A1, ag- pain, usually within one minute of full wrist JFPONLINE.COM VOL 66, NO 8 | AUGUST 2017 | THE JOURNAL OF FAMILY PRACTICE 493 TABLE 1 Common corticosteroids and injection doses2-4 Medication Dose Betamethasone sodium phosphate/betamethasone acetate 1.5-3 mg for tendon sheath/small joint Hydrocortisone 25-100 mg for carpal tunnel Methylprednisolone acetate 20-80 mg for tendon sheath/small joint Triamcinolone acetonide 10 mg for tendon sheath/small joint flexion), or thenar muscle wasting are highly including nerve damage, are exceedingly indicative of CTS (compression of the me- rare, but injury can occur, given the proximity dian nerve at the transverse carpal liga- of the digital nerves to the A1 pulley. ment in the carpal tunnel). It is important ❚ Patient is a child? Refer children with to check for CTS when examining a patient trigger finger or thumb to a hand surgeon for for trigger finger because the 2 conditions evaluation and management because the in- frequently co-occur.6 (For more on CTS, see dications for nonoperative treatment in the page 496.) pediatric population are unclear.9 Treatment: Consider corticosteroids first Carpometacarpal arthritis: First-line treatment for patients with trigger Common, with many causes finger or thumb is a corticosteroid injection Osteoarthritis of the first carpometacarpal into the subcutaneous tissue around the ten- (CMC) joint is the most common site of ar- don sheath (FIGURES 1 and 2). (For this indica- thritis in the hand/wrist region, affecting up tion and for the others discussed throughout to 11% of men and 33% of women in their 50s the article, there isn’t tremendous evidence and 60s.10 Because the CMC joint lacks a bony for one particular type of corticosteroid over restraint, it relies on a number of ligaments for another; see TABLE 12-4 for choices.) Up to 57% stability—the strongest and most important of cases resolve with one injection, and 86% of which is the palmar oblique “beak” liga- resolve with 2,8 but keep in mind that it may ment.11 A major cause of degenerative arthritis take up to 2 weeks to achieve the full clinical of this joint is attenuation and laxity of these benefit. ligaments, leading to abnormal and increased Patients with multiple trigger fingers stress loads, which, in turn, can lead to loss of can be treated with oral corticosteroids (eg, a methylprednisolone dose pack). Peters- Veluthamaningal et al performed a system- TABLE 2 atic review in 2009 and found 2 randomized controlled trials involving 63 patients (34 re- Possible adverse effects ceived injections of a corticosteroid [either of steroid injections methylprednisolone or betamethasone] and Anaphylaxis lidocaine and 29 received lidocaine only).2 The corticosteroid/lidocaine combination Depigmentation of the skin was more effective at 4 weeks (relative risk Elevated blood glucose levels [RR]=3.15; 95% confidence interval [CI], Infection 1.34 to 7.40).2 Nerve injury If 2 corticosteroid injections 6 weeks apart fail to provide benefit, or the finger is Pain at injection site irreversibly locked in flexion, surgical release Subcutaneous fatty atrophy/necrosis of the pulley is required and is performed Tendon/fascial ruptures through a palmar incision at the level of the Reprinted with permission from: Waryasz GR et al. R I Med A1 pulley. Complications from this surgery, J. 2017.4 494 THE JOURNAL OF FAMILY PRACTICE | AUGUST 2017 | VOL 66, NO 8 HAND AND ARM PAIN FIGURES 1 AND 2 Trigger finger/thumb injection* ALL FIGURE PHOTOS COURTESY OF: MANUEL DASILVA, MD OF: MANUEL DASILVA, ALL FIGURE PHOTOS COURTESY 1. Clean the area with alcohol, chorhexidine, or iodine. 2. Use ethyl chloride spray prior to injection to provide temporary injection site pain relief. 3. Palpate the metacarpal head volarly. The A1 pulley is securing the flexor tendons at this level. 4. Inject the area proximal to the metacarpal head with a mixture of lidocaine/steroid (TABLE 12-4). 5. Feel the tendon sheath fill with the liquid mixture with your non-injection fingers. The patient typically reports immediate improvement in the clicking/triggering and/or pain that prompted the visit. 6. Palpate the A1 pulley as you flex and extend the metacarpophalangeal joint to see if the clicking/triggering and/or pain has improved. *The clinician performing
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